Thursday, August 1, 2019

The Butterfly Ultrasound in Global Health

The black appearing object on the far left is a vein which is not compressible and therefore indicates there is presence of a clot. 

The most fun I had on this trip was being able to introduce the Butterfly Ultrasound to the trainees. For those of you who have been following along on my Global Health journey you may have picked up on the recent excitement over a handheld ultrasound probe that plugs in to your phone. This tech is so incredible for so many reasons--it has an incredible price point of $2000 USD versus the larger machines which can be up to $20-40K!! The image quality is great and the portability makes it easy to take to the most rural of places! I have now used this device in Rural Bangladesh at the Rohingya Refugee camps, in Nepal, in Ethiopia and will go on to use this in a project with Bridge to Health in Kenya and Uganda! In the image above we diagnosed a blood clot in the leg of a patient with cervical cancer. In the images below there was a patient who was found to have a lung abscess and I wanted to show the trainees what this may look like on ultrasound. ( All photos taken with permission ) We spent the rest of the day asking several patients if they would allow us to perform simple ultrasound to identify normal and abnormal pathology. While the training session itself was limited to the week that I was present we really focused on some basic concepts and luckily the physician who is mainly in charge of the Medical ICU at Ayder is well trained in ultrasound and so with a local expert there is even more of an incentive for trainees to practice and continue to identify important pathology that may aide in early intervention and better patient outcomes. 
examining a patient's lung with the butterfly ultrasound
a lung abscess on lung ultrasound-what you cannot see is the presence of an outer capsule of this fluid filled structure and lung tissue surrounding it

Early Recognition is life-saving

Today’s lesson is in “early recognition”. I have probably said this over a million times in my short career thus far but I truly think that early recognition and early action are the pieces missing in resource-limited settings. In resource limited areas it is difficult to decide when that early intervention should occur. Frankly, ICU medicine as we know it in the US is a very resource intensive and costly intervention--it has to be redefined in resource-limited countries. I feel very strongly about the power of education and that is not just at the level of health care providers but community level education.  I am referring to going out in the community and talking about the signs/symptoms that should bring people into the hospital, it is far too often that we see the end result of a disease process, when it is too late to act. It is even more important that this early recognition occurs especially when a patient is IN hospital. While on rounds this morning we discussed the new admission, she is a patient who came in with nausea and vomiting, with a history of prior abdominal surgeries. A tube was placed in to her stomach to help decompress her stomach, an X-ray was pretty convincing for bowel obstruction. Over the next 12 hours she started having abdominal pain and there was a concern that her obstruction was worsening so she was taken to the operating room. There she notably had a perforated intestine and had low blood pressures during the procedure. She was taken to the Post op area and for three days continued to have low blood pressures. By the time she came to the medical ICU we were seeing blood pressures of 66/30 (as seen in the picture). I will tell you--when we see this in a medical ICU in a resource-rich country the nurses are already grabbing the pressor medication to help support the blood pressure so that vital organs can be perfused. In many resource limited settings such as this one there may be only one medication available, usually it's Dopamine which is a medication we do not reach for anymore. If the patient requires an additional medication to support his/her blood pressure the patient's family will need to go purchase this medication from the pharmacy and then return with it. Time is crucial in this setting--the longer the patient's blood pressure remains this low the more injury there is to the kidneys, to the brain, to the heart, to all of the vital organs. Unfortunately this patient's family could not afford the appropriate medications and this patient despite everything we COULD do within our capabilities, did not survive. Because of the limitations of the hospital system, of space, the availability of a ventilator--this patient was not able to receive timely interventions. 

This is the devastating reality of what medicine looks like in these parts of the world. 

A triumph for our trainees but a tragedy for the patient

The patient gave permission for all photos to be taken and published here

It is difficult sometimes in medicine to temper the interest and maybe even excitement over seeing something abnormal, and reminding ourselves that there is a patient attached to that rare or interesting finding. In teaching at the bedside it is important to remind our trainees that we must respect the true teacher in the room--the patient. Today’s focus is a patient who I am so sad about. He is a 21 year old male who came to Ayder with shortness of breath, he was found to have a significant amount of fluid around his heart and luckily when he came the CT scanner was working so he was able to obtain a scan which showed a large mass sitting inside of his chest. The location of this mass was worrisome for several things including lymphoma. He was evaluated for several different types of infections, fungal and TB especially. Tuberculosis (TB) can really present as anything. After all that was completed he was started on steroids under the presumed diagnosis of Lymphoma. Biopsies were taken, the fluid was drained, he remains on a ventilator because the mass is so big that it is compressing his trachea. Given that he has no indication for sedation, he is getting only intermittent doses of thiopental as needed(a medication we really do not use in the US but is cheap and available here)—this is such a stark contrast to our patients back home who generally end up requiring some level of sedation even continuous infusions to keep them calm and comfortable on the ventilator—I imagine its because we have a lower threshold to start these medications and of course they are more readily available. Back to the patient—he was biopsied and we await the results however given the concern for progression it was decided that he empirically be started on chemotherapy. We shall see how he does—I hope for the best for him, he has his entire life ahead of him, he is awake and interactive and even jokes around with us. Human beings and their capacity for resilience is truly something to behold. The depths of pain people can go through and still remain positive is awe-inspiring to me.

Cow Horn Injury--wait what's that?!

Image result for generalized tetanus
A depiction by Sir Charles Bell of a soldier with Tetanus (from 1890)

There was a time that being in a new environment, not knowing where anything was, or not having any cell service nor maybe even wifi, was terrifying and anxiety provoking. This career in global health has helped me to release that fear somewhat; don’t get me wrong it is still intimidating and always a humbling experience but that initial fear of the unknown has started to melt away or rather transform into excitement and anticipation of what these new experiences will bring, for instance, my first experience with Generalized Tetanus. 

On my first day at Ayder University Hospital in Mek’elle I rounded in the ICU and saw my first case of generalized tetanus. The patient had a testicular injury via cow horn—meaning he was essentially head-butted by a cow. I listened on rounds as this was presented and quietly asked the student next to me what “cow horn” was…she looked at me puzzled, and answered, “You know, like a cow, ‘moo’”. Between the laughter and embarrassment I remembered the rural scene on the drive into the city and had to remind myself “you are no longer in Philadelphia”.  After that moment passed my next question was whether or not the tetanus vaccine was widely available, while the answer is yes, it seems that actual compliance in obtaining it is the difficult part especially in rural parts of Ethiopia. Men are more inclined to get tetanus than women because of the fact that most women of age have had children and it is a part of the antenatal care received. Tetanus can cause painful spasms from such minimal stimulation, the patient requires the mechanical ventilator and frequent doses of sedation. If he is to recover it could take up to 4 weeks of time! 

My Return to Ethiopia (delayed posts)

Image result for map of ethiopia with mekelle and addis

This year I was asked to bring some critical care lectures and ultrasound training to Mek’elle, Ethiopia. If you recall, last year I had the pleasure of working at Black Lion Hospital in Addis Ababa, the capital of Ethiopia. It was a wonderful experience that was provided by the East African Training Initiative—a group that initiated out of Columbia University and over the years has partnered with several other academic institutions, to bring a Pulmonary Fellowship to Black Lion Hospital. Now years after its inception the program has trained and dispersed several well-trained Pulmonologists who are now all over the country. Mek’elle is a beautiful city about an hour plane ride away from Addis. I was greeted by greenery and beautiful rolling hills as we descended on to Mek’elle. The drive to the hotel displayed the rural areas outside of Mek’elle and within 20 minutes we arrived in the city center. After 24 hours of travel I am exhausted but excited to see what Ayder University Hospital has to teach me!

Thursday, May 9, 2019

I will never cross any border line without thinking of today

The crisis in Venezuela has left its citizens without proper healthcare, with gross inflation leading to virtually worthless currency and lack of consistency in the education system as well as violence and economic instability. This crisis is not new--it has been ongoing for years but tensions have been rising recently which have led to a mass exodus out of Venezuela. Neighboring Colombia has been bearing the brunt of this migration, doing its best to accept everyone they can. At the legal border crossings (one of which is seen above) there are several conditions for which migrants can enter : they must have proper documentation, they must have a pre existing medical appointment or a temporary work permit or children who are now in school in Colombia may be accompanied by their parents. The vast majority of those crossing are doing so at unsafe and unsanctioned sites on the border which is what you see in the picture below.

This process is dangerous and yet thousands cross daily, women with small children and I mean even neonates !! They are carrying as much as they can and they are braving the gang activitiy which exists primarily to benefit from those crossing (charging a tarriff). Colombian police are stationed everywhere doing what they can to prevent extortion of those crossing but it is an overwhelming sight to behold. Many are crossing through Colombia with plans to WALK to neighboring countries because they cannot afford to pay for a bus ticket. Along the way are humanitarian aid in the form of shelter, food, vaccines/healthcare (which are NOT available in Venezuela thereby increasing the prevalence of preventable diseases ie Measles). The first refuge spot after the border is approx 20 plus miles away. We crossed many "caminantes", the walkers, making their way to Ecuador or Peru or Chile, a trek that could take over a month. 

Along the way we happened across a group of women and children. Three mothers to be exact, one pregnant of 5 months and holding her 2 year old son, another carrying a newborn and another minding the other very small children. We had to stop and help further them along to the next refuge down the road, the sky was turning dark and it was about to start pouring rain. We dropped them at a shelter where at least another hundred migrants were taking shelter for the night. In the morning they would all set out , again on foot, to the next shelter along the route to their destination country. (Consent obtained for the photo below)

Back in Cucuta we had a very productive trip, visiting the main public hospital that attends to the majority of the Venezuelan migrants as well as the vulnerable Colombian population as well. However due to the complexity of the health care system it's quite difficult to obtain follow up care let alone the service of sub Specialist Consultants. There is a large majority of Venezuelan women who go through an entire pregnancy without any pre natal care! Our mission was to assess the need for capacity building--it is clear that the emergency department at this hospital is overwhelmed, "collapsed" as they say here in Colombia. We identified all the right persons to help us implement a course in ultrasound which could potentially cut down the time needed to evaluate patients and help the turn over rate in the ER. We are also of course going to have volunteers here on the ground providing direct medical care in the highest areas of need, general medicine, pediatrics, and maternal care. BUT, all of that fell to the background after really witnessing what is happening at the border. 

I will leave you with this. At one point, while visiting the border crossing we heard rifles in the distance. We dove for cover, people were running and the police ran into the area of gunfire. Within minutes it had ceased and we soon learned we were far enough away to have remained safe. The altercation was initiated between to groups of traffickers fighting over territory. What struck me was how "normal" this seemed for all involved. Even those I witnessed crossing at the unsanctioned site--their faces were hardened, they didn't exhibit the same look of shock that I had on my face. I cannot believe we live in a world where this situation feels normal or usual for anyone. 

My heart hurts for Venezuela but I truly am uplifted by the motivation of Colombia to help its neighbors. The effort on the ground is tremendous and I look forward to any opportunity to contribute to this humanitarian crisis.

Monday, May 6, 2019

Bienvenido a Cucuta!

What a beautiful country this is. Cucuta, Colombia is surrounded by beautiful mountains. The people are wonderful and welcoming and yet it is clear that a crisis abounds.  Sharing the border with Venezuela, Colombia has been the entry site for over 200,000 Venezuelan migrants and potentially more as people are entering the country through illegal and frankly, unsafe entry sites. Imagine the desperation in Venezuela if women are carrying their children miles upon miles, crossing at unsafe borders and continuing to walk as far as Peru or Chile--a trek that could take MONTHS on foot. This crisis is not a new one-it has been ongoing for several years and has lately been reaching a critical mass as tensions continue to rise in Venezuela. Across the border on the Colombian side there are upwards of 40 NGOs doing what they can to support the excellent Colombian physicians and nurses who are just overwhelmed as the sheer number of patients continues to rise. Some of the most commonly seen medical issues are related to pregnancy, including maternal deaths, malnourished mothers and babies as well as sequelae of chronic medical disease such as hypertension and diabetes. Then of course, there is the issue that vaccinations are not possible in Venezuela and so Measles is on the rise--at point of entry one of the very first things offered are vaccinations. However, just as in any mass migration there is the concern of the host community as well. Just like any country, Colombia has its share of less fortunate people--unable to receive proper care because they themselves cannot afford to do so. So, as we saw in Bangladesh, how can a country which is itself struggling in some respects to financially care for their own, be expected to do so for such a large population of migrants? And even with that financial stress--the overall sentiment of those we have met today in the public health sector is overwhelmingly optimistic and positive. It is a tremendous thing to see. The main lessons I learned today are that just as in Bangladesh or Ethiopia or some of the other countries I have worked in, it is important to seek the guidance of regulatory agencies such as the Health Secretary. Every country has protocols and policies in place which should not be circumvented as our success is contingent on a solid partnership. Luckily our staff here on the ground are absolutely wonderful and well plugged in and connected to all the right people to allow for productive discussions on how we can play a role.

Far Left: Yesmith Garay (our brilliant coordinator in Cucuta), Middle: The Health Secretary of Cucuta